Chapter 9 – Munchausen Syndrome by Proxy

Test Items:

1. The DSM-V does not use the term, Munchausen Syndrome by Proxy. Instead, the same types of behaviors are called: a. Making My Child Ill Mania b. Factitious Disorder Imposed on Another c. Post-Partum Psychosis d. Differential Identity Disorder by Proxy

Answer: B a. Sir Thomas Stevens b. Sir William Gates c. Sir Roy Meadow d. Sigmund Freud

2. Who coined the term Munchausen Syndrome by Proxy?

Answer: C

3. A mother who says her child had ten seizures, when only one seizure occurred, is guilty of: a. exaggerating b. fabricating c. inducing d. all of the above

Answer: A

4. A caregiver who injects a non-diabetic child with insulin is guilty of: a. exaggerating b. fabricating c. inducing d. all of the above

Answer: C

5. If a mother says that her infant stopped breathing and had to be resuscitated when this never happened, she is guilty of: a. exaggerating b. fabricating c. inducing d. all of the above

Answer: B a. unlike claims of physical illness, nobody is hurt by a false educational claim b. these claims are a hassle for the school district, but they do not impact the child c. these claims are very costly to school districts d. there have been no claims of MPS in an educational setting

6. Which of the following is true with regard to false claims of illness or disability in an educational setting.

Answer: C a. victimization is usually short lived b. victims are usually infants and toddlers c. victims may suffer unnecessary pain as a result of the parent’s actions and/or medical procedures d. more than one child in a family may be a victim

7. Which of the following is NOT true about MPS?

Answer: A a. Adolescents b. Children in elementary school c. Infants and toddlers d. The elderly

8. are the most common victims of MPS.

Answer: C

9. Most perpetrators of Munchausen Syndrome by Proxy are: a. Fathers b. Mothers c. Babysitters d. Grandmothers

Answer: B

10. The main motivation behind Munchausen Syndrome by Proxy appears to be: a. the sadistic desire to cause pain b. extreme dislike of the child c. getting attention d. a desire to have fewer children

Answer: C

11. When Libow interviewed adult survivors of MPS, he found that a. They had no negative symptoms from their earlier victimization b. When looking back at the abuse, none of the adults were aware, at the time, that anything was wrong c. Most of the adults had sought mental health help to deal with their victimization. d. Most of the adults had lasting physical problems, but they were well adjusted psychologically.

Answer: C a. a mother who resists allowing further tests or procedures b. a mother who seems disinterested in the medical treatment c. a mother who is seen as shy and quiet d. a mother who does not appear to be relieved by good news

12. Which of the following is considered suspicious when evaluating a case for possible Munchausen Syndrome by Proxy?

Answer: D

13. Many mothers who are guilty of Munchausen Syndrome by Proxy have a background in: a. business b. law c. healthcare d. law enforcement

Answer: C a. Munchausen Syndrome by Proxy b. Pediatric Condition Falsification c. Malingering by Proxy d. Factitious Disorder by Proxy

14. Which of the following diagnoses would be appropriate for a case in which a child was being made ill by their caregiver, regardless of the caregiver’s motivation?

Answer: B a. Munchausen Syndrome by Proxy b. Pediatric Condition Falsification c. Malingering by Proxy d. Factitious Disorder by Proxy

15. Which of the following diagnoses would be most appropriate for a mother who told everyone her child had cancer so that they would give her money to help pay for treatment?

Answer: C

16. The mortality rate associated with MPS is estimated to be a. less than 5% b. 6 to 10% c. 20 to 25% d. Over 30%

Answer: B

17. According to Libow’s study, adult survivors of MPS tended to place blame on a. the non-offending parent who did not protect them b. the offending parent c. themselves d. all of the above

Answer: B

18. According to Libow’s study, most adult survivors of MPS indicated that a. had no long term effects from the maltreatment b. did not seek therapy to help themselves as a result of the maltreatment c. their experiences with MPS had a significant, negative impact on their adult life d. that they now engaged in MPS with their own children

Answer: C

19. The mission of MAMA is to a. prevent Munchausen Syndrome by Proxy. b. fight false allegations of Munchausen Syndrome by Proxy. c. accuse doctors of Munchausen Syndrome by Proxy. d. fight to eliminate video surveillance

Answer: B

20. Dr. Roy Meadow’s expert testimony was called into question due to his problems with: a. understanding the diagnosis of Munchausen Syndrome by Proxy b. his diagnosing a disorder he had named c. improper statistical testimony d. the fact that he was paid to provide testimony

Answer: C

21. Restricting a parent’s access to a child when one suspects Munchausen Syndrome by Proxy generally requires a. a doctor’s note b. Child Protective Services intervention c. a court order d. The parent’s access cannot be restricted

Answer: C a. While Munchausen Syndrome by Proxy is rare, experts expect that the incidence may increase as professionals become more aware of the syndrome. b. Munchausen Syndrome by Proxy is one of the most common forms of child maltreatment c. Munchausen Syndrome by Proxy is less common than neglect, but more common than sexual abuse d. None of the above is true.

22. Which of the following is true with regard to the incidence of Munchausen Syndrome by Proxy?

Answer: A

23. The Fourth Amendment to the U.S. Constitution protects citizens from a. having to testify against family members b. government interference with how they raise their children c. unreasonable search and seizure d. having to testify in cases where they are the defendant

Answer: C a. All victims are under the age of 10 years b. 95% of victims are infants or toddlers c. Almost all victims are 5 years old or older d. Approximately 25% of victims are over the age of 6 years

24. With regard to the age of victims with Munchausen Syndrome by Proxy, which of the following is accurate?

Answer: D a. By videotaping the caregivers suspected of Munchausen Syndrome by Proxy, the authors were able to see that none of them were maltreating their children. b. Evidence of Munchausen Syndrome by Proxy was found in more than half of the suspected cases. c. The mothers who were abusive were almost all African American. d. The true victims of Munchausen Syndrome by Proxy were nearly all male children.

25. Which of the following is true regarding the study by Hall, Eubanks, Meyyazhagan, Kenny and Johnson (2000) using covert video surveillance?

Answer: B

Short Answer Questions:

1. What is the relationship between the terms “Munchausen Syndrome by Proxy” and “Factitious Disorder Imposed on Another”?

Answer: Munchausen Syndrome by Proxy is the name that has been used to refer to cases in which a parent makes their child ill or claims the child is ill. It is derived from stories of Baron Munchausen who was alleged to have told many tall tales. In contrast, Fictitious Disorder Imposed on Another is the name for the same behaviors that appears in the DSM-V.

2. Give an example of exaggeration, one of fabrication, and one of inducing.

Answer: Many possible answers. As an example: Exaggeration – a child experiences sleep apnea once per hour and the parent claims it is 20 times per hour.

Fabrication – a parent claims that a child had seizures when there were no seizures Inducing – a mother forces her child to ingest castor oil until he vomits each day and then brings him to the doctor and claims he is not gaining weight.

3. List 5 perpetrator characteristics associated with MPS.

Answer: Any 5 of these: - mothers

- present initially as “normal, good” caretakers

- accomplished liars, deceivers; believable

- have extensive health care knowledge

- history of being abused themselves

- more likely to suffer from a somatizing disorder, borderline personality disorder or depression

- may add or change health care providers frequently

- use their victims as objects to satisfy their need for attention

- no prior CPS involvement

- “dramatic flair”

- history of symptom/illness falsification for themselves

4. Define Pediatric Falsification Syndrome

Answer: Pediatric Falsification Syndrome is a proposed diagnosis that means only that a child is being made ill or described as ill when they are not. This diagnosis describes what is happening to the child, but does not speak to parental motivation.

5. List 5 possible outcomes associated with child victims of MPS

Answer: Any 5 of these:

- Pain and suffering from induced symptoms

- Pain and suffering from medical tests

- Permanent disability

- Death

- Psychological problems

- Immaturity

- Problems with Separation Anxiety

- Irritable and/or aggressive

- Attention Deficit Disorder

- Post-Traumatic Stress Disorder (PTSD)

- Poor school performance

- Missed Social and Educational opportunities

- Having siblings who are injured

- Embarrassment or shame

- Removal from the home

- Child may develop Munchausen Syndrome

6. If you suspected that a child you were working with was the victim of MPS, what should you do first?

Answer: Carefully review the child’s file and then pull together and interdisciplinary team to discuss your suspicions. Try to involve every professional involved with the child’s case.

Additional Case Studies for Chapter 9

1. Clin, Ferrant, Dupont, & Papin (2009) present a detailed medical case of a 9-month-old girl who was poisoned by her mother resulting in recurrent caustic esophagitis. This three page reports details the infant’s hospitalization and includes a discussion and conclusions.

Clin, B., Ferrant, O., Dupont, C. & Papin, F. (2009). Recurrent caustic esophagitis: A clinical form of Munchausen syndrome by proxy. Child Abuse and Neglect, 33, 293-295. https://doi.org/10.1016/j.chiabu.2008.09.007

2. Rosenberg (1988) details a case (3 pages long) about a 9-year-old boy suffering from Munchausen Syndrome by Proxy. The author covers the boy’s hospitalizations, brief descriptions of the mother and father, and describes the assessment and outcome.

Rosenberg (1988). Recent issues in child maltreatment. In The New Child Protection Team Handbook. Eds: D. C. Bross, R. D. Krugman, M. R. Lenherr, D. A.

Rosenberg, & B. D. Schmitt. Garland Publishing, Inc.

3. Drs. Roesler and Jenny (2009) summarize 115 cases referred for possible MPS. They give brief case examples of 16 children (one paragraph each). Of the 115 cases, 87% met their criteria for medical child abuse. The authors then present the following data about the 87 cases: Types of Unnecessary Medical Care Received, a Comparison of Children

Found to Be Victims and Those Who Were Not, Medical Specialists Involved (e.g., gastrointestinal, psychiatric, neurological), Types of Treatment Given, and Interventions.

Roesler, T. A., & Jenny, C. (2009). Description of 115 cases referred for possible Munchausen Syndrome by Proxy. In T. A. Roesler, & C. Jenny (Eds.), Medical Child Abuse: Beyond Munchausen Syndrome by Proxy (pp. 131-154). American Academy of Pediatrics.

4. Ruth Kannai (2009) presents a four page case summary of a woman, Sarah, who was guilty of Munchausen Syndrome by Proxy. The victim was her fourth child, a daughter, Joy.

The case covers Joy’s repeated hospitalizations and the reluctance of the family’s general practitioner to suggest Munchausen Syndrome by Proxy to the other doctors involved.

Kannai also provides some of the mother’s history. The case summary is followed by a four page discussion of the case.

Kannai, R. (2009). Medical family therapy casebook: Munchausen by mommy. Families, Systems, & Health, 27(1), 105-112 https://doi.org/10.1037/a0015031

Video Suggestions

1. The movie The Sixth Sense contains a scene (chapter 15 on the dvd) about a child who died as a victim of Munchausen Syndrome by Proxy. The main character in the movie is a young boy, Cole, who can see dead people and the ghost of a young girl, Kyra, uses him to reveal that she was a victim of Munchausen Syndrome by Proxy and that her younger sister is now at risk. The scene takes place during

Kyra’s memorial service and you overhear a number of comments that would point to Munchausen Syndrome by Proxy. Kyra than shows Cole a video she made of her mother poisoning her.

2. The show Munchausen Moms (2007) includes video of covert video surveillance of Munchausen Syndrome by Proxy cases. The video is 45 minutes long and is available for free on Amazon Prime (with ads); it can be rented for $1.99 or purchased for $7.99.

3. Numerous videos are available that cover the Gypsy Rose case – for example Gypsy’s Revenge and The Act are series that document the case while Mommy Dead and Dearest is a 1 hour and 22 minute movie produced in 2017. It is an HBO production that is available with HBP and HBO on Amazon.

Discussion Topics

1. A complex and difficult case type is the recurrent allegation of child sexual abuse that is unfounded. In these cases one parent, usually the mother, repeatedly presents the child for examination for alleged sexual abuse. There are either no medical findings, or findings that are not definitive for abuse. Assuming the mother does not seem to be alleging sexual abuse to gain attention, the case would not meet the criteria for Munchausen Syndrome by Proxy. However, repeated questioning and medical exams may have a negative impact on the child that is similar to that seen in Munchausen Syndrome by Proxy. The mother’s motivation may be to gain custody, true concern about sexual abuse, a desire to hurt the alleged perpetrator, or a combination of these. It has been suggested that a new label, ‘recurring sexual abuse allegations’ be used for these cases (Lindahl, 2009).

a. What are the similarities and differences between Munchausen Syndrome by Proxy and recurring sexual abuse allegations?

b. How important is the mother’s motivation to determining a diagnosis?

c. Discuss the use of the label malingering by proxy in relation to recurring sexual abuse allegations.

2. Schreier and Libow (1994) list 13 guidelines for suspecting and identifying MPS (in a Table on page 111). For some, or all, of the 13 guidelines have students argue that a normal, non-abusive situation might entail the same behavior: Table 1. Guidelines for suspecting and identifying MBPS

1. A child who has one or more medical problems that do not respond to treatment or that follow an unusual course that is persistent, puzzling, and unexplainable

2. Physical or laboratory findings that are highly unusual, discrepant with history, or physically or clinically impossible

3. A parent (usually the mother) who appears to be medically knowledgeable and/or fascinated with medical details and hospital gossip, appears to enjoy the hospital environment, and often expresses interest in the details of other patients’ medical problems

4. A highly attentive parent who is reluctant to leave her child’s side and who herself seems to require constant attention

5. A parent who appears to be unusually calm in the face of serious difficulties in her child’s medical course while being highly supportive and encouraging of the physician, or one who is angry, devalues staff, and demands further intervention, more procedures, and the like

6. The suspected parent may work in the health care field herself or profess interest in a health-related job

7. The signs and symptoms of a child’s illness do not occur in the parent’s absence (hospitalization and careful monitoring may be necessary to establish this causal relationship)

8. A family history of unusual or numerous medical ailments that has not been substantiated and raises questions about the reporter’s veracity

9. A family history of similar sibling illness or unexplained sibling illness or death

10. A parent with symptoms similar to her child’s own medical problems or an illness history that itself is puzzling and unusual

11. A suspected parent with an emotionally distant relationship with her spouse; the spouse often fails to visit the patient and has little contact with physicians even when the child is hospitalized with serious illness

12. A parent who reports dramatic, negative events, such as house fires, burglaries, car accidents and the like, that affect her and her family while her child is undergoing treatment

13. A parent who seems to have an insatiable need for adulation or who makes self-serving efforts at public acknowledgement of her abilities

(Schreier & Libow, 1994, p. 111 – as modified from Schreier & Libow, 1993) https://doi.org/10.1016/S0022-3476(05)82934-8

Schreier, H. A., & Libow, J. A. (1994). Munchausen by Proxy Syndrome: A modern pediatric challenge. The Journal of Pediatrics, 125(6), 110-115.

Test Items a. They do not experience negative emotions b. They can experience positive emotions even during difficult times c. They rarely experience positive emotions d. None of the above are true

1. Which of the following is true of resilient people?

Answer: B a. They seem not to have a fight or flight response b. They always chose to fight rather than flee c. They always chose to flee rather than fight d. They react appropriately to stress and then return to normal functioning when threat has passed

2. Which of the following is true of resilient people?

Answer: D a. Lower blood pressure b. Decrease in physiological arousal c. Feelings of safety d. All of the above

3. Which of the following is associated with positive emotions?

Answer: D a. Child and Youth Resilience Measure b. Child Behavior Checklist c. Ego-Resiliency Scale d. Trauma Symptoms Checklist for Children

4. Which 14-item test was designed to measure how well a person can adapt their behavior to meet the demands of changing situations?

Answer: C a. Child and Youth Resilience Measure b. Child Behavior Checklist c. Ego-Resiliency Scale d. Trauma Symptoms Checklist for Children

5. What is the name of the 28-item test designed to assess the level of support a person has to be resilient across individual, relational, community and cultural domains?

Answer: A a. Child and Youth Resilience Measure b. Child Behavior Checklist c. Ego-Resiliency Scale d. Trauma Symptoms Checklist for Children

6. Which test requires parents and teachers to assess a child’s behavior and emotional functioning?

Answer: B a. At least 50% of maltreated children are resilient when resiliency is measured across several domains. b. Between 16 and 35% of maltreated children are resilient when resiliency is measured across several domains. c. On average, males are more likely to be resilient following maltreatment than are females. d. Resiliency does not change over time – once resilient, always resilient.

7. Which of the following statements about resiliency is true?

Answer: B a. The abuse started earlier for the non-resilient group b. The abuse started later for the non-resilient group c. The perpetrator was a family member more often for the non-resilient group d. Physical force was used more often with the non-resilient group

8. What did Liem, James, O’Toole and Boudewyn (1997) find about the differences between resilient and non-resilient sexual abuse victims?

Answer: D a. Authoritative b. Authoritarian c. Permissive/Indulgent d. Neglectful

9. Which parenting style is most strongly associated with resiliency?

Answer: A a. Difficult b. Easy c. Slow-to-warm-up d. None of the above

10. Which temperament is associated with resiliency?

Answer: B a. Intelligence is always positively associated with resiliency b. Intelligence is never associated with resiliency c. The findings are inconsistent d. None of the above

11. Which of the following is true regarding the research findings on intelligence and resiliency?

Answer: C a. Discussing the abuse b. Minimizing the abuse experience c. Reframing the abuse in a more positive way d. Dwelling on the abuse

12. Which of the following is NOT associated with resiliency following sexual abuse?

Answer: D a. Jenny, who has two long alleles for the 5-HTT gene b. Sally, who has one long allele and one short allele for the 5-HTT gene c. Beth, who has two short alleles for the 5-HTT gene d. All three girls would be equally likely to develop depression

13. Which of the following children would be most at risk for developing depression following child maltreatment?

Answer: C a. Jenny, who has two long alleles for the 5-HTT gene b. Sally, who has one long allele and one short allele for the 5-HTT gene c. Beth, who has two short alleles for the 5-HTT gene d. All three girls would be equally likely to develop depression

14. Which of the following children is the most likely to be resilient following child maltreatment?

Answer: A

True/False

1. If a child is resilient after maltreatment, it means the perpetrator is not guilty of a crime.

Answer: False

2. Resilient children do not experience negative emotions.

Answer: False

3. People who are resilient experience positive emotions even during difficult times.

Answer: True

4. People who suffer less extreme forms of maltreatment are more likely to be resilient than those who suffer from more extreme maltreatment.

Answer: True

5. Males are more likely to be resilient following child maltreatment than are females.

Answer: False

6. Resilient adults tend to have an external locus of control.

Answer: False

7. Having two short alleles for the 5-HTT gene decreases the chances that you will be resilient following child maltreatment.

Answer: True

Short Answer Questions

1. Define resiliency.

Answer: resiliency is being able to recover easily from difficult circumstances; the ability to bounce back and persevere; being able to adjust to misfortune; adaptable

2. List 3 things you should do when attempting to measure resiliency.

Answer: 1. Measure at different times as resiliency may change across the lifespan. 2. Measure across various domains. 3. Collect information from multiple reporters

3. List 2 factors that cause incidence rates for resiliency to vary across studies.

Answer: 1. The way resiliency is defined impacts resilience rates. The big question is whether the absence of pathology or above average functioning constitutes resiliency. 2. Rates of resiliency vary based on how many factors are assessed. As the number of factors assessed increases, the rate of resiliency found decreases.

4. Describe three mechanisms by which a supportive adult may help a child be resilient.

Answer: 1. A stable, caring adult may allow the child to build a sense of trust in others and the belief that they will receive help when they need it. 2. Being cared for may increase the child’s sense of worth and thereby lead to resiliency. 3. A caring adult may reverse the negative neurobiological changes associated with experiencing adverse situations.

5. List five community factors that are associated with resiliency.

Answer: Any 5 of these: good schools, high quality social services, good health care services, prosocial clubs, religious organizations, libraries, recreation centers, or good public safety.

6. Why might religion and/or spirituality be positively associated with resiliency? Answer: Spirituality may provide meaning for victims and assure them of their worth despite what they have experienced. Participation in organized religion may also increase the amount of social support available.

Additional Case Studies

1. Murphy (2009) presents a 7 page case study about a middle aged man named Mac with a history of child abuse. Murphy explains the maltreatment and how Mac’s negative symptoms are reduced after taking part in client-centered therapy.

Murphy, D. (2009). Client-centered therapy for severe childhood abuse: A case study.

Counseling and Psychotherapy Research, 9 (1), 3-10. doi: 10.1080/14733140802655992

2. Herrenkohl, Herrenkohl, and Egolf (1994) present a one page case study about three siblings who are the victims of child maltreatment. Two of the children are doing well and one is struggling. The authors then address protective factors and discuss the case in terms of the interaction between personal factors and the environment.

Herrenkohl, E. C., Herrenkohl, R. C., & Egolf, B. (1994). Resilient early schoolage children from maltreating homes: Outcomes in late adolescence. American Journal of Orthopsychiatry, 64 (2), 301-309.

Video Suggestions

1. The Unloved is a British television movie (1 hr 49 min.) about a resilient 11-yearold girl who is the victim of abuse at the hands of her father and who then enters a children’s home. The movie was first broadcast on May 17, 2009. It is available from Amazon for $11.93.

2. Post-Trauma Wellness (release March 20, 2012). This video has a lecture format and presents the work of the Center for Post Trauma Wellness. Their focus in on the recover from abuse. This dvd is available from Amazon for $19.95.

3. This 3:20 minute video clip is available on youtube. Dr. Yo Jackson of the University of Kansas talks about studying resiliency in children. The clip was uploaded on Sept. 29, 2009. Dr. Jackson defines resiliency, discusses how she plans to assess resilient children, and her hopes for the results.

http://www.youtube.com/watch?v=JNimix56mHM http://www.youtube.com/watch?v=U-3S7jVBBG4 http://www.youtube.com/watch?v=Ha47I2OiKB4 http://www.youtube.com/watch?v=Nmq6JFzQ4Zk

4. This 9:38 minute video clip is available on youtube. Barbara Walters interviews Ellen DeGeneres (2007). The clip, Ellen DeGeneres (Sexual Abuse, Phone Call to God, Coming Out) reviews Ellen’s successful career, her experience with sexual abuse by her step-father and her coming out about her sexuality.

5. This 4:55 minute video clip is available on youtube. Naomi and Wynnona Judd speak out about their experiences with childhood sexual abuse in the hopes of helping others. The video was uploaded on April 7, 2011. The video was part of the Oprah Winfrey Show (ABC).

6. This 10:38 minute video clip is available on youtube. Jim Cantelon interviews Maury Blair about his abuse history, how he has overcome his experiences, and how he helps others. The video was uploaded September 21, 2010. Maury Blair is the author of the book Child of Woe.

7. Derek Clark was the victim of child abuse. He then spent 13 years in foster care. Today, he is a successful motivational speaker. At his website http://www.iwillnevergiveup.com/

You can find links to 6 video clips where he uses his experiences to help others.

Discussion Topics

1. Have the students research a famous person who suffered child maltreatment and seems to be resilient. What protective factors did/does this person have that helped them succeed despite negative life experiences?

2. Among people who are resilient following child maltreatment, some dedicate a great deal of time and/or money to helping other victims. What do you think makes some people chose this course of action? What is their motivation?

3. Is it valuable for celebrities to speak publically about their own maltreatment? It what ways might it be helpful? It what ways might it be harmful?

4. Which factors do you think are most important for resiliency? Do you think caregiver, community, victim, or genetic factors have the greatest impact on resiliency?